1. Aasis Unnanuntana, MD, MSc Case Discussion: Bone Forming Drug Associate Professor in Orthopaedic Surgery Department of Orthopaedic Surgery, Siriraj Hospital, Mahidol University, Bangkok 1 13 th November 2015 MBOG Annual Meeting 2015

2. Conflict of Interest I do not have a financial relationship with any commercial interest

3. Case 1 A 75-year-old Thai female diagnosed with femoral neck fracture on December 2012 and received bipolar hemiarthroplasty lab20/12/55BMD Calcium8.1 -2.0 at FN Albumin2.6 PTH45.67 25(OH)D16.17 -1.0 at LS BUN17.2 Cr0.9

4. Follow up Started treatment with alendronate (about 2 years) lab20/12/554/2/5610/10/5623/01/5722/05/57 Calcium8.19.29.59.39.1 PO 4 4.44.03.4 Albumin2.64.24.3 PTH45.6735.327.8424.0934.21 25(OH)D16.1735.7437.4528.1034.21 BUN17.211.123.713.012.9 Cr0.90.890.880.840.96 CTX0.2370.1690.1200.090 P1NP112.4010.4719.4719.27

5. After 2 years of treatment New clinical VCF at T8 Advise change alendronate to Forteo Patient denied due to financial problem –Continue with alendronate (generic alendronate, aledronate sandoz)

6. Continue follow up 2.5 years after initial fracture hip –She fell down again 11/5/58 –The diagnosis was fracture neck of left femur Treat with bipolar hemiarthroplasty Advise to use Forteo

7. Case 2 An 81-year-old woman Outdoor independent without assisting device 4-week history of low back pain and buttock pain after fell from a standing height Her pain was exacerbated by activity such as walking, rising from a chair and rolling over in bed The pain worsens with back flexion and better with back extension

8. History No night and rest pain No radicular pain and weakness She has history of progressive kyphosis at her back for the last 5 years Her pain has been progressive to the point that she couldn’t get up from a chair Now she needs to ambulate with wheelchair

9. Past history Underlying disease –Hypertension –Peptic ulcer –No history of malignancy No history of calcium supplement Menopause at the age of 40 year

10. Physical examination Back  Kyohotic deformity at T-L spine  Mild tender at mid-line of L3-5  Marked tenderness over the sacral area (S1-2)  No stepping  Normal neurological status Others: unremarkable

11. Plain radiograph

13. MRI (sagittal) T1 SAGITALT2 STIR SAGITAL

14. MRI (coronal) T1 CORONALT2 STIR CORONAL

15. MRI (axial) T1 AXIALT2 STIR AXIAL

16. Sacral insufficiency S1-2

17. Management Short period of bed rest and early mobilization ( ambulate as tolerate with walker ) Pain control –Tylenol with codeine –Analgesic balm Patient education –Fall prevention

18. Operative indication ?

19. Operative indication 1.Unstable fracture 2.Symptomatic nonunion  Risk of nonunion Prior pelvic irradiation therapy Chronic steriod use 3.Intractable pain  Restrict mobility after a period of conservative treatment

20. Bone mineral density T score (spine L2-L4) = -2.97 T score (femoral neck) = -3.81 Outside institute data

21. Lab 1/3/12 BUN13 Creatinine0.8 LFTnormal Total calcium9.2 Phosphorus3.6 Vitamin D39.8 PTH24.34 ALP145 P1NP159.5 Beta-cross Laps0.412 Osteoporosis work up

22. Management Osteoporosis treatment –Calcium 1200 mg/day –Vitamin D2 to achieve vitamin D levels ≥ 30 ng/mL –Teriparatide 20 mcg injected once daily

23. Indication for Teriparatide 1.T-score ≤ -2.5 SD with evident of vertebral fractures ≥ 2 levels 2.T-score ≤ -2.5 SD with evident of hip fracture 3.T-score ≤ -3.5 SD with evident of vertebral fractures 1 level 4.Failure of bisphosphanate treatment (>2 year)  New evident of vertebral or hip fracture  Decrease of BMD ≥ 3% per year at spine  Decrease of BMD ≥ 5% per year at hip

24. Follow up (6 weeks) Pain score improvement (10 -> 2) Indoor independent without walker Don’t need to take analgesic drug No drug side effect Physical examination –Mild tender over the sacral area –Motor grade V all –Sensory intact

25. MRI (sagittal T2STIR) baseline20 weeks

26. MRI (coronal T2 STIR) baseline 20 weeks

27. MRI (axial T2 STIR) baseline 20 weeks

28. Postmenopausal women with closed distal end radius fracture were randomly assigned to placebo, 20 mcg and 40 mcg of teriparatide (n=34, each group) Injection witin 10 days of fracture 8 weeks of treatment 28 JBMR 2010

29. Median time from fracture to first X-ray evidence of complete cortical bridging was 9.1, 7.4 and 8.4 weeks for placebo, 20 mcg and 40 mcg of teriparatide, respectively Significant shorter in teriparatide 20 mcg compared to placebo (p=0.006) Limitation by its clinical relevancy 29 Results

30. 65 patients with pelvic fractures 21 received 100 mcg of PTH 1-84; 44 control CT scans every 4 th week until fracture union was observed VAS, TUG 30 JBJS 2011

31. Median time to fracture healing 7.8 weeks for the treatment group and 12.6 weeks for the control group (p<0.001) At 8 weeks after treatment, fracture healed 100% and 9.1% in treatment and control group, respectively VAS and TUG were significantly better in treatment group 31 Results

32. Thank you for your attention MBOG Annual Meeting 2015